Transcript Exploring Medicaid Waivers - Infant & Toddler Connection

Exploring Medicaid
Waivers
Debra Holloway
The Arc of Virginia
Family Involvement Project
Different Institution Different Waiver
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Waivers provide funding for a wide
variety of services for people of all
ages who have disabilities or are
elderly so that they may remain in
their homes and communities rather
than an institutional placement such
as a hospital, nursing home
or ICFs/MR (intermediate care facility)
Medicaid
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Means “Low income” – Wrong!
Waiver eligibility is not dependent on
income.
Waiver Must be Cost
Effective
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Virginia’s waiver programs for the
elderly and disabled are expensive but
still less costly than compatible
institution care.
The elderly and disabled represent
30% of Medicaid program recipients.
What are the services?
Different Waivers have
different services.
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Adult Day Health Care
Assistive Technology
Case Management
Companion Services
Crisis Intervention/Stabilization
Day Support
Environmental Modifications
Family Caregiver Training
Nursing Services
Nutritional Supplements
Personal Care Services
Personal Emergency Response System
Prevocational Services
Residential Support
Respite
Skilled Nursing
Supported Employment
Therapeutic Consultation
Transition Coordination
There are seven waivers administered by
the Commonwealth of Virginia
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Elderly or Disabled with Consumer Direction
(EDCD)
Individual and Family Developmental Disabilities
Supports (IFDDS)
HIV/AIDS
Technology Assisted (Tech)
Mental Retardation (MR)
Day Support
Alzheimer’s Assisted Living (AAL) Waiver managed
by the Facility and Home-Based Care Unit
Mental Health Waiver (Demonstration Waiver)
Elderly or Disabled with Consumer Direction
Waiver (EDCD)
 Technology Waiver (Tech)
 Individual and families with Developmental
Disabilities Waiver (DD)
 Mental Retardation Waiver
(MR Waiver, ID or intellectually disabled)
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Consumer-Directed Services
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Individual or family caregiver directs and controls who, how, and
when services are provided
Virginia offers consumer-directed services in 4 Waivers:
– Elderly or Disabled with Consumer-Direction Waiver (since 2005)
- Personal Care, Respite
– Developmental Disabilities Waiver (since 2000) - Personal Care,
Respite, Companion
– Mental Retardation Waiver (since 2001) - Personal Assistance,
Respite, Companion
– AIDS Waiver (since 2003) – Personal Assistance, Respite
Consumer-Directed Services
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Individual is the employer of record with the IRS
Service Facilitator (SF) writes documentation of need based
on information from the individual, monitors the service and
provides support as needed to the individual so that the
individual can be an employer of their staff
SF provides training on recruiting, interviewing staff, how to
handle difficult situations, how to complete employment
paperwork, etc.
SF provides list of people who have said they want to work as
consumer-directed staff and shows how to place an
advertisement for attendants, companion aides and respite
workers (the list and ads do not have to be used)
DMAS (using a contractor, PPL) pays the attendants,
companion aides and respite workers on behalf of the
individual
Consumer-Directed Employees
Attendants, Companions, Respite
Workers
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Consumer-Directed employees may not be – Parents of minor children or spouses of the
individual receiving consumer-directed services
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If the Consumer-Directed employee lives
with the person receiving services – Service Facilitator must have objective written
documentation as to why there are no other
providers available to provide care
Elderly or Disabled with
Consumer Direction Waiver
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This waiver is constructed to allow persons
to remain in the community that meet
nursing facility level of care.
Current enrollment 14,034
No waiting list
Screening is conducted by the Preadmission
Screening team made up of a representative
from The Department of Health and the
Department of Social Services using the
Uniform Assessment Instrument (UAI)
Eligibility
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This waiver serves the elderly and
persons of all ages with disabilities.
The individual may receive this service
through a service provider or though
consumer direction.
An individual can remain on the
waiting list for another waiver while
being served by the EDCD Waiver.
Criteria
Qualify for Medicaid (individual)
 Meet long term care criteria according to
Uniform Assessment Instrument (UAI)
Pre-Admission Screening Criteria:
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– Functional capacity (the degree of assistance an individual
requires to complete activities of daily living); and
– Medical or nursing needs
– Risk of nursing facility placement
Examples
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Functional Dependencies:
bathing, dressing, toileting, transferring,
eating/feeding
Medical and nursing needs:
catheter care, supervision for adequate
nutrition and hydration, therapeutic exercise
and positioning, management of those with
sensory, metabolic, or circulatory
impairment.
Getting Started
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Request for screening, contact your local
Health Department
Schedule visit with pre-admission screening
teams of the Department of Health &
Department of Social Services.
Completed Medicaid application (child’s
information only!)
Services
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Adult Day Health Care
Personal Care (agency or consumer directed)
Respite 720 hrs. (agency or consumer directed)
Personal Emergency Response System (PERS)
Assistive Technology ($5000 max calendar year)
Environmental Modifications ($5000 max calendar
year)
Transition Services ($5000 max)
Transition Coordination
Technology Assisted
Waiver (Tech)
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No age limit to eligibility
No waiting list
Currently serving 319 individuals.
Eligibility
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Serves individuals who need a medical devise to compensate
for the loss of a vital body function and requires substantial
and ongoing skilled nursing care to remain safely in their
homes.
Screening: UAI is used for adults and Tech Waiver scoring
tool is used for children
The Department of Medical Assistance Services (DMAS)
reviews individual’s private insurance policy for private duty
nursing benefits
Case management provided by DMAS nurses
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Different rules for children and adults
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Criteria
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Doctor must certify need for care; and
need substantial and ongoing skilled
nursing care; and
Care must be cost effective; and
Primary caregiver must be trained and
accept responsibility for 8 hours or
more per day
Screening Process
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DMAS receives a referral from community
resources, family, other parties
DMAS completes a Scoring Tool to determine if the
individual meets the specialized care criteria for the
waiver
If the criteria is met DMAS conducts a home
assessment.
DMAS works with the primary caregiver, referral
source to secure appropriate nursing care for the
individual in the home
DMAS authorizes needed services for the provider
agency upon the start of care
Services
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Private Duty Nursing (16 hours maximum a
day, except children may have 24 hours a
day for the first 30 days after hospital
discharge)
Personal Care (adults only)
Respite Care (360)
Environmental Modifications ($5000)
Assistive Technology ($5000)
Durable Medical Equipment
Transition Services ($5000)
Individual and Family
Developmental Disabilities
Support Waiver (DD)
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Wait list is maintained by the
Department of Medical Assistance
Services (DMAS)
Recipients served FY07 594, and 640
are waiting.
Can be placed on the waiting list at
age 5 years 8 months
Eligibility Criteria
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“Related Conditions” Waiver
Must be 6 years of age and over and meet
the related conditions criteria, including
autism; and
Individual must not have a diagnosis of
Mental Retardation.
Meet the level of care for admission to an
ICF/MR. The individual must meet 2 out of
7 levels of functioning.
Screening
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The Virginia Department of Health Child
Development Clinics will screen individuals with the
Level of Functioning (LOF) Survey which is the
assessment instrument used to determine eligibility
to for an ICF/MR
You can download a copy of the “Request for
Screening” from www.dmas.virginia.gov. Compete
the form and fax or mail it to the CDC. The
psychological assessment is a requirement of the
screening determination.
RELATED CONDITIONS
also referred to as developmental
disability
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Severe chronic disability
Attributable to a condition, other than mental illness
Manifested before the age of 22
Likely to continue indefinitely
Results in substantial limitations in 3 or more areas
of major life activity
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Self-care
Understanding and use of language
Learning
Mobility
Self-direction
Capacity for independent living
Transitioning from MR to
DD Waiver
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Annually each child receiving MR
Waiver services who will be 6 years of
age the following year can be up for
consideration for transfer to the DD
Waiver.
If the child meets DD Waiver eligibility
the child can transition to the DD
Waiver.
Services
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Adult Companion (CD & Agency/up to 8 hours a day)
Assistive Technology ($5000)
Crisis stabilization
Crisis supervision
Environmental Modifications ($5000)
In-home residential
Prevocational
Companion Care
Day support
Skilled nursing
Supported employment
Therapeutic consultation
PERS
Family/caregiver training (80 hours a year)
Respite care (720)
Personal attendant services
Transition Services ($5000)
Mental Retardation
Waiver (MR)
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Day-to-day MR waiver operations are managed by
the Department of Mental Health, Mental
Retardation and Substance Abuse Services
(DMHMRSAS)
Locally, MR Waiver services for individuals are
coordinated by case managers employed by
Community Services Boards
Wait list - Waiting list as of 12/08 4,375
7,942 waivers approved
400 new MR Waiver slots funded, 200 available
July 1, 2009, 200 available January 1, 2010
Eligibility
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Individuals must have an evaluation that
reflects their current level of intellectual and
adaptive functioning.
Six and over – a psychological evaluation
with a diagnosis of mental retardation.
Six and under – either a psychological or
standardized developmental evaluation that
states the child has a diagnosis of mental
retardation or is at developmental risk.
Criteria
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All individuals receiving MR Waiver
services must meet the ICF-MR level
of care.
Case Manager completes a “Level of
Functioning Survey.” The individual
needs to have significant needs in two
or more of the survey’s seven
categories.
Waiting List
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Urgent
Non-Urgent
Urgent Criteria for the MR
Waiver
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Primary caregivers are both 55 yrs or older (or if 1,
is 55 or older)
Living with a primary caregiver who is providing the
service voluntarily and without pay and they can’t
continue care
There is a clear risk of abuse, neglect, or
exploitation
Primary caregiver has chronic or long term physical
or psychiatric condition significantly limiting ability
to provide care
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Individual is aging out of a publicly funded
residential placement or otherwise becoming
homeless
Individual lives with the primary caregiver and
there is a risk to the health or safety of the
individual, primary caregiver, or other individual
living in the home because:
– Individual’s behavior presents a risk to himself or
others OR physical care or medical needs cannot
be managed by the primary caregiver even with
generic or specialized support arranged or
provided by the CSB
MR WAIVER WAITING LISTS
Urgent and Non-urgent
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CSBs and DMHMRSAS
maintain Urgent and NonUrgent lists
CSB maintains Planning list
CSB provides individual with
written notice if placed on a
waiting list and if there is a
change in status to another
list
CSB determines who is the
most urgent
Only after all Urgent needs
are met statewide will Nonurgent needs be served
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Slot moves with you to a
different town in VA
Vacant or new slots are
allocated by the CSB unless
there is no need in the
CSB’s area
Non-urgent = meet criteria
for the MR Waiver,
including needing services
within 30 days, but don’t
meet Urgent criteria
Planning list = need
services in the future
Services
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Adult Companion Care
Assistive Technology ($5000)
Congregate Residential
Crisis Stabilization/Supervision
Day Support
Environmental Modifications ($5000)
Family/caregiver Training
In-home Residential
Medication Monitoring
PERS
Personal Care (Agency or Consumer Directed)
Prevocational Services
Private Duty Nursing/Skilled Nursing
Respite Care (720) (Agency or Consumer Directed)
Therapeutic Consultation
Supported Employment
Transition Services ($5000)
Early Periodic Screening,
Diagnosis, and Treatment
(EPSDT)
Medicaid benefits available to children under the age
of 21
 Must be eligible for Medicaid
 Monitor to prevent health and disability conditions
from occurring or worsening, including services to
address such conditions
 Treatment to “correct or ameliorate conditions,”
including maintenance services
EPSDT
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Immunizations
Check ups and lab tests
Mental health assessment and treatment
Health education
Eye exams and glasses
Hearing exams and hearing aids & implants
Dental services
Personal care, nursing services
Other needed services, treatment and measures for
physical and mental illnesses & conditions
Medical Necessity
The medical justification for a service
must accompany the request for
EPSDT treatment services
-Services not covered
Respite
Environmental Modifications
Vocational
Educational
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Health Insurance Premium
Payment Program (HIPP)
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If an individual receiving waiver
services has private health insurance,
Medicaid will be the individuals
secondary insurance
DMAS may reimburse the individual for
all or a portion of their monthly private
health insurance premium
HIPP
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Application must be completed
separately from the Medicaid
application.
1-800-432-5924
Visit www.dmas.virginia.gov scroll to
“Client Services” click on “More
Services” then click on “HIPP
Information”
Recipient Appeal
A person may appeal if their benefits
are:
-Terminated
-Denied
-Suspended
-Reduced
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Medicaid Appeals
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Fair Hearing
Right to challenge decisions and actions
regarding Medicaid
Appeal must be requested within 30 days of
the decision or action that you disagree with
Decision should be issued by the Hearing
Officer within 90 days
Steps
Request an appeal or review
(804)-371-8488
 Notify appeals division in writing
 Be specific about what you want
-Results in a hearing
-Decision made
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MYTH or FACT
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All persons with a disability of MR/ID
will qualify for MR Waiver. MYTH
I can be on a wait list for the DD
Waiver or the MR Waiver while I am
receiving services from another
Waiver. FACT
Waiting Lists
MR Waiver has 2 waiting lists
Urgent and Non-urgent:
CSB determines who is the most urgent to receive available MR
Waiver funding
DD Waiver waiting list
First come, first served with wait list numbers assigned
10% of available money allocated for emergency situations
DMAS staff determine who receives available emergency slots
No waiting list for AIDS, Alzheimer’s, EDCD and Tech
Waiting lists are permissible, but waiting lists must
move at a reasonable pace. What is a reasonable
pace?
The Arc of Virginia
Family Involvement Project
Debra Holloway
Family Involvement
Project Manager
888-604-2677
ext. 103
[email protected]
The Arc of Virginia
888-604-2677
www.arcofva.org